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Renal Failure
Renal Failure
o Renal causes:
Could be glomerular (glomerulonephritis) or tubular (acute tubular
necrosis) or interstitial nephritis.
o Post renal:
Tubular obstruction (stones or crystals) or could be uretral stones or
urethral obstruction (posterior urethral valve obstruction).
Treatment of ARF:
It's mainly supportive but we can give immunosuppressants. If it's pre renal
failure we should give fluid to increase the volume or we could use
iontropes (digoxin), if the patient doesn't improve on fluid and the volume
is good then I have to stop fluid to prevent the overload.
If the patient takes antibiotics or other drugs then we should reduce the
dose and adjust it accordingly.
Hemodynamic support and respiratory support if there's pulmonary edema
or overload.
Fluid management is important; could be fluid giving or restriction.
To be on the safe side always give urine output + insensible loss.
ARF starts with oliguria then when start recovering he develops polyuria so
if we don't give the maintenance he will develop ARF again and again.
For electrolytes, the most important one to monitor is K because it's the
only electrolyte that can kill the patient so we have to give him K free diet
and adjust according to his K level. If you want to give K you shouldn't give
it continuously.
Acid base level should be monitored and the acidosis should be corrected
because it will not be corrected by itself (the kidneys are the major site for
acidity control).
Ca is decreased in sever cases so you should provide it.
Phosphorus is increased in ARF but it's not significant whatever the level.
When do we do dialysis??
o if the failure is rapidly progressive and there's no steadiness in creatinine
levels.
o Major electrolyte abnormalities (especially hyperkalemia) unresponsive to
medical therapy; so we restrict the K, give K oxalate, protect the heart and
correct the acidosis then if all these aren't working we have to do dialysis.
o Fluid overload (hypervolemia) not responding to diuretics or fluid
restriction and you need to give fluids to the patient then we should start
him on dialysis.
o Uremic Pericarditis (can't be treated without dialysis).
o Uremic encephalopathy.
It's not called chronic renal failure any more because the definition has
spread to include chronic kidney problems with normal function (normal
creatinine level) like kidney scars or persistent hematuria or proteinuria or IgA
nephropathy with normal kidney function. So now it's called chronic kidney
disease.
It's defined as a state of irreversible kidney damage and/or reduction of
kidney function, which can lead to future decreases in kidney function, e.g. a
patient with kidney scar and normal function he may develop renal failure in
the future.
Stage
1
2
3
4
5
Description
Kidney damage with normal or GFR
Kidney damage with mild GFR
Moderate GFR
Severe GFR
Kidney failure
You should know that some patients stay in a certain stage and don't
develop renal failure, e.g. 50% of IgA nephropathy patients don't develop renal
failure, they only have hematuria.
- GFR:
GFR is the sum of functioning glomeruli so a reduction in GFR implies a
decrease in the number of functioning glomeruli.
We can calculate the GFR by either imaging studies or by Schwartz formula
which depends on the age, gender and body size (height) so:
GFR = k * (height or length / serum creatinine)
K depends on the age and gender.
Newborns have small GFR due to there immature kidney.
GFR of male > GFR of female but you should know that GFR > 90 is normal
in both sexes.
Normal GFR in children and young adults
Age (gender)c
Schwartz equation
Mean GFR SD
mL/min/1.73m2
GFR=0.33*(Length/SCr) in Preterm
GFR=0.45*(Length/SCr) in Term
GFR=0.45*(Length/SCr)
GFR=0.45*(Length/SCr)
GFR=0.55*(Length/SCr)
GFR=0.70*(Length/SCr)
GFR=0.55*(Length/SCr)
40.6 14.8
65.8 24.8
95.7 21.7
133.0 27.0
140.0 30.0
126.0 22.0
The younger the patient, the more likely the cause to be congenital or
structural (VUR, neurogenic bladder, polycystic kidney, obstruction ..etc) or
HUS.
As he/she grows up, glomerular diseases are more likely.
So the etiology of chronic kidney disease:
o Congenital renal anomalies were present in 57 percent of cases.
o Glomerular disease was present in 17 percent of patients.
o Other causes accounted for approximately 25 percent of cases (around
20% of these causes are idiopathic).
CLINICAL PRESENTATION:
o Early stages of CKD (asymptomatic).
o Direct kidney injury or disease (ARF on top of CRF).
o Incidental findings of an elevation in the serum creatinine concentration
and/or abnormalities on urinalysis.
o Detection of congenital or structural anomalies by imaging studies.
o Poor growth.
o Symptoms and/or signs of severe renal impairment (acidosis).
o Systemic symptoms and findings due to a concurrent systemic disease (skin
rash in case of SLE or seizures etc).
COMPLICATIONS OF CKD:
The doctor didn't explain anything about the complications so for more
information go to the slides.
The follow up of the patient depends on the stage of the disease; a patient
in the early stages you should see him every 3 6 months but a patient in the
end stages you have to see him every week or maybe every day.
Every visit we should check the GFR, diet, growth parameters, PTH,
haematology, CVS and so on.
Management:
General principals:
o Treat reversible renal dysfunction ( a patient with CRF has UTI then you
have to treat the UTI aggressively).
o Prevent or slow the progression of renal disease.
o Treat the complications of CKD.
o Identify and adequately prepare the child/family in whom renal
replacement therapy will be required.
o Anemia:
Could be due to iron or folate or B12 deficiency Or due to decreased
production of erythropoietin or frequent blood loss during dialysis. So we
give iron and folate to be sure then we give erythropoietin.
Hgb levels should be between 10 12 not above that because they are
prone to dyslipidemia and atherosclerosis, not below 10 because it will
affect cognitive functions.
o nutrition:
They have very limited choices regarding their nutrition so they have to
avoid K rich foods and Ph rich foods like canned food, juices etc.
o growth:
They have growth retardation due to many factors (anemia,
osteodystrophy, recurrent illnesses and admitions, growth hormone
resistance etc).
o dyslipidemia.
o uremic bleeding.
o uremic Pericarditis.
The Dr. didn't talk about the treatment of the last three complications.
Renal replacement therapy:
It depends on the family, patient, severity of the condition and availability
of the service.
Three types of renal replacement therapy:
o Renal transplant.
o Hemodialysis.
o Peritoneal dialysis.
We do living transplant means that one of the parents should donate so if
the parents are healthy and there's a match then we prefer the transplantation.
But if the parents are old and have health problems (DM, HTN) or the family
has a kidney problems (polycystic kidney disease or familial condition) then we
don't do the transplant from the family.
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